The use and abuse of 'benzos'

The early 1960s saw a dramatic increase in the use of benzodiazepines, better known as minor tranquilisers or sleeping pills. We've since learned how addictive these tranquilisers can be, and why they're designed for short-term use only. So why, in 2015, are they still being prescribed for anxiety and insomnia? Lynne Malcolm and Olivia Willis report.

'In my early twenties, I started having panic attacks, and was put on benzos, unaware of the effects they could have on me. I wasn't told much about them, and was just put on them regularly until eventually I started abusing them.'

Ben has been taking drugs for 14 years. His use of benzodiazepines began as part of his treatment for severe anxiety and insomnia.

I was on methadone, Suboxone for 10 years, a heavy user of heroin and painkillers, ice as well, but benzos have by far been the hardest thing I've had to go through.

Ben, drug user

'For a while I couldn't function without them. I would not go to work if I didn't have any, because I couldn't cope with the anxiety and the panic attacks that were coming on.'

In addition to Xanax and clonazepam, Ben relied heavily on Valium, which he sought through both medical prescriptions and illegal means.

'I was probably spending about $150 every second day,' he says.

'I was on methadone, Suboxone for 10 years, a heavy user of heroin and painkillers, ice as well, but benzos have by far been the hardest thing I've had to go through and to come off. Benzos are just a nightmare.'

According to Ben, prescription medication is harder to kick than any illicit substance.

'There's more treatment for heroin, you can go on methadone and it can control your withdrawals. But having a dose of Valium, I still get withdrawals, it doesn't totally hold me.'

Valium, now known as diazepam, is one of the most common anxiety disorder medications, and is typically prescribed by doctors to relieve stress and anxiety or to help with sleep.

Part of the benzodiazepines family, the drug is used to slow down the activity of the central nervous system and messages travelling between the brain and the body.

'These drugs came into the medical marketplace in the early 1960s, after some development looking into medications that could be used in anaesthesia,' says Dr Mike McDonough, a physician of addiction medicine and toxicology.

According to McDonough, the quantity and variety of benzodiazepines quickly proliferated. The drugs were lauded as one of the most successful discoveries of the psychopharmacological revolution of the 1950s.

However, while the drugs' efficacy generated optimistic expectations amongst professionals and the public, it also brought about a higher risk of dependency and abuse.

'In the late '70s, and certainly into the early '80s, there was increasing concern expressed by medical groups and community groups about benzodiazepine dependence,' says McDonough.

'People were staying on what were considered normal doses for the treatment of things like anxiety or insomnia for several weeks, months and even longer, and having great difficulty stopping or reducing the dose.'

Following two unsuccessful class actions, the UK Medicines Council published a report on benzodiazepine use in the early 1990s, with guidelines for safe use of the drugs.

'Essentially two to four weeks was suggested at that time, and right up to the present day, the most recent guidelines on the usefulness of these medications is very clearly short-term use for particular situations,' says McDonough.

Despite this, it is estimated that one in 50 Australians now takes benzodiazepines for longer than six months, typically for problems relating to anxiety and sleep.

The medications are commonly divided into short, intermediate and long acting categories, and there is a range of brand names available for each.

'There are several bona fide evidence-based situations in acute care medicine, certainly in hospital-based and procedural-based medicine, where benzodiazepines have an immediate, tried and proven effectiveness,' says McDonough.

In Australia, the most common benzodiazepines prescribed include temazepam, used as a sleeping tablet, diazepam, alprazolam, also known as Xanax, and oxazepam.

'When we look at the more wide-scale use of benzodiazepines in the community, it is clear from the evidence and the guidelines ... that short-term use—and that is usually two to four weeks, tops—is the recommended period of time for a person to be exposed, beyond which there is an increased risk of becoming dependent,' says McDonough.

So is prescribing benzodiazepines for anxiety and panic attacks still the most appropriate treatment?

'Many people, up to one in four or thereabouts, can have some experience of mental health problems during their life, and that's commonly anxiety or depression,' says McDonough.

Most medical guidelines stipulate that in general, first-line treatment should be psychological, and include practices such as cognitive behavioural therapy.

'For second and third line consideration, for people with truly disabling anxiety disorders, there are other medications, and they include things like the antidepressants ... but not benzodiazepines,' says McDonough.

'The guidelines clearly articulate that if [benzodiazepines] are going to be considered in the context of a comprehensive treatment approach to, say, anxiety disorder management, they are only ever recommended to be considered for short-term periods.'

Even so, McDonough believes they still are being overprescribed, especially to elderly patients.

'A disproportionately high number of these people are on benzodiazepine-based hypnotics ... They are of great concern to us as a population of vulnerable people who are far more at risk for falls, confusion and incontinence because the tranquillising effect is broad on the body in general.'

Critical body processes like balance control, control over defecation, urination, speech and thinking can all too be impaired by benzodiazepine use.

'The problem that presents to many nurses and other healthcare workers and doctors in aged care facilities is you find the aged patient already on these medications for sometimes years,' says McDonough.

According to McDonough, research undertaken on elderly people being assisted to 'get off' benzodiazepines demonstrated patients 'feeling better and functioning better' at the end of a gradual withdrawal period.

'It does appear to improve not only their functioning, but their quality of life.'

This withdrawal period, however, is what Ben—who sought help with his longtime dependence on diazepam—found most challenging.

'Just the severe anxiety, the insomnia, it's hard to explain the feelings of unreality, just real spaced-out feeling, the muscle spasms, the hand tremors ... so many withdrawals, I could name them for quite a while.'

Ben, who began his treatment with 40 milligrams per day with 10 per cent reductions from there, still experiences many ups and downs.

'When I got to 20 milligrams of diazepam I was really struggling, so we started doing it a milligram at a time, probably every two to three weeks.

'I've had a couple of slight setbacks where I've got down to three milligrams, needed to take extra because of the severe anxiety and withdrawals, and I've gone back to five. I'm currently down to 4.5 milligrams.'

According to McDonough, treatment for benzodiazepine addiction begins with a patient's readiness to accept the notion that they might be helped by coming off medication.

'The exit plan, that's incredibly important, followed by a planned strategy for gradual reduction and continued reappraisal, and that being explained to the patient so that they know they are not just going to be plucked from the benzodiazepines, they going to be gradually guided and supported on that journey.'

The physician says it's about educating the patient on the realities of the withdrawal process, and highlighting the potentially substantial health benefits if the treatment is successful.

'We now know, for example, that mortality rates are different for people on long-term tranquillisers compared to the rest of the population. Fall rates are different, confusion and even dementia are different.'

Ben, meanwhile, has used his drawing and cartooning skills to create of a poster for Reconnexion, a not-for-profit organisation in Melbourne that provides support for people dependent on tranquillisers. The poster represents the 'dos and don'ts' of benzodiazepine withdrawal.

According to Ben, 'there are a lot of bad days', but it's important to keep seeking support and stay in contact with your drug counsellor.

'Benzos are designed to stop anxiety, but when they stop working for you it just intensifies it and it's just very hard to control.

'I'm going to have to just practice a lot of relaxation, get into yoga. I started shiatsu, which is helping me sleep, a relaxation technique, and just keep up with my counselling and calling the support line at Reconnexion. I don't want to have to go through this again.'

According to McDonough, 'adherence to clinical guidelines' is the most important take-home message with respect to benzodiazepine use.

'The argument against that, that is commonly used by doctors and others, is that not everybody fits the clinical guidelines all of the time, so there are cases where we have to step outside some of those guidelines and prescribe differently.

'But broadly, clinical guidelines should assist all practitioners in avoiding getting into prescribing situations that lead to long-term unnecessary dependence on drugs like benzodiazepines.'

Comments (11)

LC :

19 Nov 2015 9:54:04am

A great informative article.

However benzos have been copping such a bad wrap. I am a sufferer of panic disorder and do have a mental health plan, where I take medication daily. I live a very productive life thanks to SSRIs and wouldn't like to dwell on what my life would have been without them. I only imagine a horrible and unpredictable life.

Benzos I have used at times when I am 'desperate' and this would mean that a prescription of benzos will last me from the point of sale until the drugs have met their use by date.

Benzos can be used quite successfully when the patient is educated and knows the risks. Unfortunately many don't, and it also relates to a lack of insight into panic attacks.

The frustration as a user of Xanax, my benzo of choice, purely because it doesn't put me to sleep at the wrong times, is that the drug is now a drug that has been sanctioned by the government. Thanks to those who abuse it, or sadly develop an addiction to it, all those who use the drug with respect like myself, now face an uphill battle obtaining it. It angers me that a responsible user such as myself, is thrown into the same basket as those who don't know how to use it correctly.

At the end of the day, I feel sad for those who have become addicted to the drug and I do understand why, yet benzos must be respected, as any other drug.

jojospanner :

27 Nov 2015 10:09:32pm

Dreadful things. No respect. Suspect motives of inventors. Women with anxiety were first line of customers. Now I wonder how many careers were derailed. When I was 18 and at university I don't remember any girl who wasn't on something. Librium, Valium, whole list of Latinized names. Bah. Humbug. And combined with alcohol? Madness.

Jobby :

19 Nov 2015 7:54:25pm

I've suffered with Generalized Anxiety Disorder and Depression since I was 16. Around 15 years ago I was first prescribed Lorazepam and continue to use it to the present day. My use of 50, 1 mg tablets, over an average of 3-4 months hasn't changed since I commenced the medication. For me it has been an absolute life saver at times and although it is highly addictive, more so than Valium, if used responsibly no other drug I have used has been as effective.

The question "So why, in 2015, are they still being prescribed for anxiety and insomnia" for me is easily answered, if used intermittently these drugs are very effective and allow people to get on with their lives as best they can. I too have abused alcohol and recreational drugs in the past to cope with anxiety and depression, as many sufferers do, however, this has always been a personal choice.

Ben is in a difficult situation but I can't see that benzodiazepines are solely to blame.

Chaplain J.R.Bunyan :

27 Nov 2015 9:02:43pm

Of course, many are now aware of the problems that can be associated with e.g.diazepam and similar medications, or, a propos of the recent discussion, codeine based painkillers, and the objectionably proposal to require prescription for all of them. For example, I am carefully dependent on codeine based medication for chronic pain - and if there is an alternative for severe pain without unpleasant side effects, I have not yet found it. (Here talk of necessary dependence rather than addiction would be sensible.) Regarding diazepam, it was prescribed for me in 1970 for a severe "breakdown" - depression and anxiety - when GPs generally knew nothing of those problems. (I was able to keep working with few knowing about what was going on.) I have used diazepam now for 45 years, normally 2 1/2 mgs daily, but occasionally in the past on stressful occasions, or very, very occasionally to get to sleep, 5mg - with 8mg rarely . There have been no noticeable side effects over all those years. It may have contributed to some memory loss but memory loss is not uncommon at my age, nearly 80. Throughout it has been an absolute blessing. I did stop taking it for some months in the mid 70s, and developed, I think as a result, an unpleasant thyroid condition that took a couple of years to go. So I went back on to diazepam. Perhaps a grumpy old man these days, I am one who is getting fed up not with helpful tablets but with innumerable nanny announcements and nanny policies, reducing and restricting adults' responsibility for their own lives. Apart from that poorer memory, I continue to be mentally active, writing books, taking part in various ex-service and many other organisations, and visiting large numbers of hospital patients weekly - not to convert them to anything but hoping to be of a bit of help where possible, not least with a listening ear, among those patients those who suffer poor and themselves depressing conditions in some of our psycho-geriatric facilities. (I might add that with regard to depressive conditions - having had long ago two very serious bouts each lasting 3 years, though I continued to work - in my case the medications for that disorder were worse than than the disorder. Others are helped by various ones. In my case what helped was having good friends, creative work, and plenty of bright light, and writing down at the end of each day 10 thinks for which to be thankful.) But we are all different. Advice on any of these matters should take that into account - and, unlike Sydney train announcements, treat people generally as responsible, mostly intelligent adults.

jojospanner :

27 Nov 2015 9:52:33pm

Even 2-4 weeks use of benzos seems too much to me. They are horrifyingly powerful. Many years ago I tried them to help with opiate withdrawels. So I got a bit of sleep but when I woke up I was more anxious than ever in my life. And it wasn't the opiate withdrawels. Quite different. They are also dangerous as hell in combination with opiates. People combine them because they think it enhances the effect of opiates but it just makes you silly and uncoordinated and liable to take too many and die. Big slab of so-called heroin deaths are from this combination. Thoroughly evil and useless drugs. Another little gift from the 'War on Drugs' - let the doctor prescribe and tell you what to do. Haha. Threw them out.

Delia :

30 Nov 2015 7:54:32am

The problem with taking benzos is that while you are on them, they seem to be working very well. I can't tell you how many comments I've read from people saying that they don't understand why benzos have been given such a bad rap because they're helping people to have more productive, healthy lives. To them I say, "You don't know what damage these drugs are doing to your nervous system until you either go into tolerance withdrawal or decide to get off of them completely. Only then will you know the horrors of withdrawal. You may be one of the lucky ones to not have to go through such hell and misery for months or years. I wish that were the case for everyone, but it's not."

I'm one of those persons who has gone through hell both tapering off the drug (first having been on Ativan and then switching over to Klonopin to taper) and being off completely. I'm almost two years off benzos, and it's been the worst thing I've ever gone through.

The nervous system gets the full brunt of the assault from benzo drugs. It's like they're "mowed down" while the drug is being taken, effectively being hijacked by the drug. A person who has taken benzos long-term may begin to notice "breakthrough" symptoms of increased panic attacks, anxiety, vertigo, tinnitus, depression, etc., not knowing that the reason is that the benzo dosage is not high enough any longer to stave off withdrawal. If they then go to the doctor to find the answers, chances are that their doctor will be absolutely clueless about the true nature of these drugs and will prescribe an additional drug or drugs to take. That additional drug or drugs can cause even more CNS problems because the nervous system becomes overloaded with its burden of not only the benzo drugs but the added side effects of the other drug or drugs.

I could go on and on about the dangers of taking these drugs more than a few days, as some people are dependent extremely quickly. They ought to be used only for very short-term medical settings. They work well for that purpose.

I would not wish benzo withdrawal on my worst enemy. It can be that bad. And by all means, taper SLOWLY if you decide to get off of them. Don't ever cold turkey. I've read about people having delayed reactions to withdrawal after having done a cold turkey, and once the withdrawal really gets underway, it could very well be protracted.

James :

01 Dec 2015 10:21:49am

I took 2 mg of klonopin for 10 years. It stopped being effective, but if I tried to stop I got horrible withdrawal symptoms. Over the 10 years, I gained 30 pounds and become agoraphobic. Finally, I had enough and decided to taper off with no help at all from my doctor. It took 2 years after the last dose before the extreme anxiety, insomnia, and gastrointestinal issues settled down. Do not take these drugs long term! Getting off was the most traumatic thing I've ever had to do, but it's so worth it when you do. I can know feel true emotions, including happiness.

edie :

30 Nov 2015 9:11:47pm

My mother was given tranquilizers in the nursing home. After an early dinner medication and out like a light. How convenient for the nursing home.ABUSE. Medically sanctioned as well.No one cares to surveil or question the culture.

Wayne Douglas :

05 Jun 2016 7:30:11pm

July 11 is World Benzodiazepine Awareness Day (W-BAD) which has been set up to help raise awareness about the risks associated with prescription benzodiazepine drugs such as Xanax, Klonopin, Valium etc.

RockyRacoon :

03 Oct 2016 4:41:18pm

I have been prescribed benzodiazepinesfor 26 years, daily use. First Xanax, then Klonopin. With the advent of the internet, I one day researched these drugs and found that many 'more advanced' countries (I'm in the USA) do not allow use of these for more than a month ! I lived in denial for a few years until I hit TOLERANCE. That is when the anxiety is no longer halted by the Benzo, and in fact returns with a vengeance, along with other symptoms, commonly depression, agoraphobia, and suicidal ideation. The time came to pay the Piper. Some Doctors will just up the dose, which just prolongs the inevitable. There is practically no infrastructure on earth to help people like me wean off of these drugs; provide the support and guidance for about a year, while the symptoms manifest. I am about 2/3 through my wean off of Benzos. The last 9 months have been quite difficult. I am lucky to have an understanding Doctor and support at home. I am not treated like a street drug addict, as are many Rx'd Benzo users who hit tolerance. All this because I had a bad panic attack one day at work, 26 yrs ago. Maybe I had too much coffee that day. The pills are pushed at us here in the USA, and pushed hard. Don't ever leave in the same room alone with a big Pharmaceutical Co. executive.